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Jackie Behm
Coagulation level guidelines for PICC insertion
Does anyone have written (or unwritten) guidelines in place for acceptable INR, APTT and PLT levels prior to PICC insertion?  Or do you have references you use to guide your practice?  Thank you!
Daphne Broadhurst
Jackie, this has been a

Jackie, this has been a frequent topic of interest on this list serv. If you perform a search on this site, with"inr" as the keyword, you will see previous posted responses to similar queries.

We do not have any formal guidelines/references to guide us. If we have a thrombocytopenic pt with platelets ~ <20 we usually recommend a platelet transfusion & insert during or immediately post-insertion, unless there is an urgent need for the line. The patient & staff are informed of the risk of bleeding. High INRs also don't preclude a PICC. We would confer with the service to ascertain whether medical intervention (i.e., vit K or fresh frozen plasma) is required prior to the procedure. If the platelets are high, aspirin may be prescribed by the attending. This was supported by an interventional radiologist who presented at an AVA conference in Savannah (unfortunately I don't have the syllabus at hand).

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

The best article ever
The best article ever written for indications and contraindications is by Marcia Ryder PhD.  It is done in 1993 and was written in the Nursing clinics of North America.  As she states and this article is well documented INR, platelets are not contraindications to a PICC line insertion.  Patients have to be assessed on an individual basis.  Platelet infusion and fresh frozen plasma as cited above can be given before the insertion.  You have to confer with the attending physician and make a decision on what is the best line.  It certainly is not a surgically inplanted line or an acute care line placed jugular, femoral or subclavian.  A peripheral line may not be a good choice for the therapy or vasculature of the patient.  That only leaves the PICC line.  Than you weigh whether the patient is going to miss their medications, lab draws or therapy as a result of not having the line.  It is a clinical risk-benefit ratio that must be made on a one to one case basis.  You cannot just have a black and white guideline of we do not place PICC lines in this patient because of these labs or medical conditions or because they have sepsis.  There is no article to give you those black and white parameters.  Last I heard Medical science is a practice.  Practice describes it all.

Kathy Kokotis

Bard Access Systems

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